Culture has been conceptualized as a diversity domain, characterized by distinct value systems, norms, and social and behavioral patterns [36]. Culture refers to the values and knowledge of groups in a society; it consists of approved behaviors, norms of conduct, and value systems [9,10]. Culture involves attitudes and beliefs that are passed from generation to generation within a group. These patterns include language, religious beliefs, institutions, artistic expressions, ways of thinking, and patterns of social and interpersonal relations [11]. Culture can also represent worldviews—encompassing assumptions and perceptions about the world and how it works [12]. Culture has two components: the observable and the unobservable [47]. The observable include things such as language, customs, and specific practices, while the unobservable include beliefs, norms, and value systems. Culture helps to elucidate why groups of people act and respond to the environment as they do [13].

On the other hand, race is linked to biology. Race is partially defined by physical markers, such as skin or hair color [14]. It does not refer to cultural institutions or patterns, but it is generally utilized as a mechanism for classification. In modern history, skin color has been used to classify people and to imply that there are distinct biologic differences within populations [15]. Historically, the census in the United States defined race according to ancestry and blood quantum; today, it is based on self-classification, with some scholars arguing that race is also a social construct, not merely biologic [21]. Racial characteristics are also assigned differential power and privilege, lending to different statuses among groups [16]. The American Anthropological Association views race as "an ideology of human differences" that then "became a strategy for dividing, ranking, and controlling colonized people used by colonial powers everywhere" [57].

On the other hand, race is linked to biology. Race is partially defined by physical markers, such as skin or hair color [14]. It does not refer to cultural institutions or patterns, but it is generally utilized as a mechanism for classification. In modern history, skin color has been used to classify people and to imply that there are distinct biologic differences within populations [15]. Historically, the census in the United States defined race according to ancestry and blood quantum; today, it is based on self-classification, with some scholars arguing that race is also a social construct, not merely biologic [21]. Racial characteristics are also assigned differential power and privilege, lending to different statuses among groups [16]. The American Anthropological Association views race as "an ideology of human differences" that then "became a strategy for dividing, ranking, and controlling colonized people used by colonial powers everywhere" [57].

Ethnicity is also a complex phenomenon and has been defined in many different ways. Alba identified four components of ethnicity [17]:

In 2018, 13.5% of the U.S. population was foreign-born [20]. Three states—California (10.7 million), Texas (4.9 million), and New York (4.5 million)—have the largest immigrant populations in the United States [24]. In California, 39% of the population is Latino; 35% is White [67]. By 2044, the United States is expected to become majority-minority country [27,69].

"African American" is a classification that serves as a descriptor; it has sociopolitical and self-identification ramifications. The U.S. Census Bureau defines African Americans or blacks as persons "having origins in any of the Black racial groups of Africa" [23]. It includes people who indicate their race as "Black, African American, or Negro," or provide written entries such as "African American, Afro American, Kenyan, Nigerian, or Haitian." As a group, African Americans have struggled for civil rights, liberty, cultural pride, and identity, giving the term sociopolitical weight as well.

Asian American groups have differing levels of acculturation, lengths of residency in the United States, languages, English-speaking proficiency, education attainment, socioeconomic statuses, and religions. For example, there are approximately 32 different languages spoken among Asian Americans, and within each Asian subgroup (e.g., Chinese), multiple dialects may be present [29,30]. The diversity of this group makes generalizations difficult.

Cancer is the second leading cause of death for African Americans [50]. In 2019, it was projected that 202,260 new cancer cases were expected for African Americans, with 104,240 of these cases occurring in women [50]. Although the overall cancer incidence is 8% lower for African American women compared with White women, the mortality rate is 12% higher [183]. The leading sites of new cancer cases among African American women are the breast, lung/bronchus, and colorectum [50]. Beginning in the 1980s, the breast cancer incidence rates among African American women increased significantly, in part because of the increased education in early detection. The incidence rates have now stabilized. Between 2006 and 2015, the breast cancer incidence rate for African American women was 0.9%, compared with 0.4% for non-Hispanic white women [50]. The death rate for breast cancer for this group is still 40% higher than for white women [50]. African American women also tend to develop breast cancer younger (e.g., before 40 years of age) [50]. African American women tend to have later-stage diagnoses of breast cancer compared with White women [183]. Furthermore, the five-year survival rate for breast cancer is the lowest for African American women compared with all other racial/ethnic minority groups and white women (82% vs. 92%) [51; 183]. Cervical cancer rates are 30% higher among African American women than their non-Hispanic white counterparts [50]. This disproportionate burden is believed to be related primarily to unequal access to health care extending to a lack of screening.

In the past, African American women had lower mammography screening rates than white women, but these rates are now only slightly higher for African American women 40 years of age and older (69% vs. 64%) [50]. Yet, this higher rate may be due to over-reporting [50]. Similarly, Pap test use is slightly higher, at 85% for African American women compared with 83% of white women [50]. In a study of 5,060 women who had scheduled Pap test appointments at a women's health clinic in Missouri, African American women had the highest percentage of "no shows" among all racial minority participants [184]. In a 2011 study of African American women who frequented beauty salons in North Carolina, several demographic variables were found to predict Pap test and mammography use [53]. African American women who had an annual household income of at least $50,000 had health insurance, were currently working, and reported being in excellent/very good health tended to have had a Pap test in the past three years. For mammography screening, age (i.e., 50 years or older), having health insurance, having had a Pap test, and reporting having excellent/very good health predicted having a mammogram in the past year. A 2021 study found that health insurance and patient-provider communication were the two main variables that predicted breast cancer screening for African American women [185].

It appears that acculturation and years of residing in the United States are variables that affect cancer rates among Asian immigrant women. In a 2019 study, Asian women who have lived half or more of their lives in the United States were almost three times more likely to be diagnosed with breast compared to their U.S.-born counterparts [147]. In another study, for Asian women who immigrate to the United States, their risk of developing breast cancer increases six-fold, and Asian women who have lived in the United States for at least one decade have an 80% higher risk of breast cancer compared with more recent immigrants [51]. It is speculated that this is due to the changes in diet, physical activity, and the environment.

Data show that breast tumors in Hispanic women tend to be localized and larger at diagnosis compared with their non-Hispanic white counterparts, perhaps explained by lower mammography screening rates among Hispanic women [59,150]. The five-year breast cancer survival rate for Hispanic women is 86%, compared with 91% for white women [51].

Like other racial and ethnic minority groups, women from Native American populations have low mammography and Pap test rates. Level of education, health insurance status, and access to health providers all impact screening rates. An estimated 16.9% Native American/Alaska Native women have not had a Pap test in the past five years [131]. In 2018, 65.3% of Native American/Alaska Native women 40 years of age and older reported having had a mammogram within the past two years, compared with 68% for White women [194].

Many cultures believe that language has power to shape reality and change the course of life events [157]. For example, some Native American tribes believe that if someone talks about cancer, particularly in the first person, this can bring about cancer [41]. Many Asian cultures also believe that speaking about taboo topics will bring about the feared event. In a study of Chinese Australian women, participants reported that thinking and speaking about cancer would bring it to fruition [75]. In the African American community, this process is referred to as "claiming;" by discussing cancer, one takes ownership of it, and therefore, there is the possibility of it happening. Conversely, if one does not discuss illness, the possibility is significantly reduced [76]. In a survey study of Muslim immigrants, some participants reported being unaware of family history of cancer, in part because information was withheld to prevent family from worrying or because speech was believed to influence health outcomes [158].

In several studies, ethnic minority immigrant women reported believing that proper hygiene reduced the risk of cervical cancer [83]. In a study of Vietnamese immigrant women, the majority believed that cervical cancer could be prevented by proper hygiene, including cleaning procedures and observances of behaviors during menstruation [5]. A study of Malaysian women revealed similar beliefs, with the women asserting that "dirtiness" in the vagina could lead to cervical cancer and the necessity for cleaning the vulva and vagina area after sex and during menses [84]. Older Chinese immigrant women have reported that unhygienic conditions in China caused germs that then mutated to cervical cancer [83].

Research involving Latina immigrant women have found that some women believed that improper care of the womb or inadequate feminine hygiene could lead to infections, which could then place one at greater risk for cervical cancer [49,165]. Attributing the development of cervical cancer to sexual activity during menstruation was also adhered to by some Latina women [85].

Some Asian cultures believe that certain foods, including deep fried foods and preserved foods (e.g., dried fish, canned foods), may cause cervical cancer [84]. In a study of Latina women, sugar substitutes, spicy foods, and foods that have been microwaved were believed to cause breast cancer [85].

In a focus group study with African American women, some participants expressed fear that a mastectomy could cause cancer to spread [86]. In another study of Haitian immigrant women, participants shared the belief that x-rays from mammography screening could cause breast cancer [74]. Latinx farmworkers were concerned the mammogram machine was dangerous and could harm the breast [198].

At the individual level, barriers to cancer screening include issues related to access to care and health literacy. Racial and ethnic minorities in the United States are significantly less likely to have health insurance, making it difficult, expensive, and inconvenient for women to obtain regular mammograms and Pap tests [92]. Over the past decade, co-payment requirements have increased with most insurance plans, and this increase is correlated with a decrease in cancer screenings [93]. Less than 70% of women in cost-sharing plans were screened, compared with nearly 80% of fully covered women. This disproportionately affects African American women, women with lower levels of education, and women in lower socioeconomic levels. Those who are uninsured are even less likely to receive screenings [94]. Lack of health insurance and higher co-payment costs emerged as barriers for Hmong women engaging in appropriate breast and cervical cancer screening [124].

Lack of a regular physician can also reduce screening rates. In one study, recent immigration and lack of a regular physician were the greatest risk factors for not having a recent Pap test among minority women [95]. Another issue is the amount of time and resources that women have to devote to their health care. In one study, Malaysian women reported being stressed by the competing demands of life, which resulted in their health being a low priority [84]. In some cultures, the patriarchal social structure limits women's decision-making authority, which can negatively impact health-seeking decisions [162]. In such cases, the well-being of others may be valued above one's own [167]. In two separate studies, South Asian and Iranian women indicated that familial responsibilities did not allow time for cancer screenings [163,167]. This may be partially the result of stricter adherence to traditional gender roles, with women responsible for all home and child care. Hispanic women in focus groups discussed similar issues regarding relegating their health needs due to their daily struggles with life maintenance issues (e.g., caring for children, cooking) [96]. Even for older women, childcare issues may remain if they are caring for grandchildren. Creating a stable home life for their families is considered more urgent for African American women than preventive health care [96,99,133].

One qualitative study noted that cancer screening is still costly in terms of time and finances for older women because they often rely on family members for transportation, resulting in absence from work and arrangements for childcare [97]. For many immigrants, family members attend healthcare appointments to serve as interpreters [98]. The perceived inconvenience is exacerbated by the locations of clinics and long waits for appointments [84,96]. Health clinics that are easily accessible or known to immigrant women have been associated with an increased probability of screening [163].

Being unable to communicate well in English is a barrier in the context of obtaining transportation, locating the clinic or office, and filling out forms [124,163]. Similarly, Native American women have reported wanting information presented verbally or in simple, easily comprehendible written language [137].

Lack of accurate knowledge about cancer and screenings also contributes to the lower rates of screening in minority populations. Fear and anxiety, stemming from misconceptions, inaccurate information, and the general unknown, often impede women from adhering to screening guidelines [168]. For example, a survey of Latina women found a common belief that breast cancer is incurable and that mammography is only necessary when symptoms emerge [61]. In one qualitative study, some African American participants did not have an understanding of the difference between self-breast exam and a mammogram [159]. Others did not know where to obtain screening [200].

Some racial and ethnic minority women have a strong preference for a female physician or provider to conduct mammograms and/or Pap tests. For some women, female providers were associated with increased comfort and mediated modesty and embarrassment issues [199]. Other women prefer a physician from their own racial/ethnic minority group. In a study of Korean American women in Hawaii, participants expressed a desire for a female gynecologist, some even travelling back to South Korea to obtain preventive care [207]. In another study, Hispanic women stated that they preferred to have a provider who was also Hispanic, but it was more important that the provider could speak Spanish [99]. Asian and Muslim women preferred a female provider due to their feelings of embarrassment and privacy about having a male provider touch them [158]. Some Asian women expressed a preference for physicians with training from prestigious medical schools; this could be partially explained by the emphasis on education in Asian cultures [99].

Developing culturally sensitive and relevant health prevention education for breast and cervical cancer screenings requires active listening. Recommendations for improving cancer knowledge among racial/ethnic minority women include [83]:

When trying to reach racial/ethnic minority women, it is important to consider how mammogram and Pap test screening messages are framed [89]. For example, the word "cancer" can evoke dread and fear for many women, with several cultures attributing the power to cause illness to the word. Similarly, some women may believe that the only "real" cancers are those in the late stages. However, if cancer screening is couched within a discussion about benign tumors, emphasizing the importance of early detection, then the message will be better received [89]. Instead of employing the word "cancer," the terms "tumors" or "lumps" could be employed as a way to start a dialogue.

In collectivist cultures, individuals' roles as part of a larger group are paramount, with an emphasis placed on interdependence [117]. There are three major elements of collectivist orientation: interdependence; familiarity, caring, and trust; and sense of obligation [117]. The family and the church are concrete representations of this cultural norm, and they influence many behaviors, including health decisions. This translates into cancer prevention and education in that the relationship, connection, and trust between the messenger and the recipient have more importance than the message [117]. Therefore, when practitioners deliver a health message in a personal manner that communicates that they can be trusted and that they care, the message will be viewed as more credible and is more likely be acted on. If a patient sees the same practitioner at every (or most) visit, there are more opportunities to establish a therapeutic alliance, ensuring that health behaviors are maintained.

Styles of communication can be classified from high- to low-context [118]. High-context cultures are those that disseminate information relying on shared experience, implicit messages, nonverbal cues, and the relationship between the two parties [119]. Love and care may not always be verbally expressed but rather demonstrated through concrete actions [175]. Members of these cultural groups tend to listen with their eyes and focus on how something was said or conveyed [118]. On the other hand, low-context cultures rely on verbal communication or what is explicitly stated in a conversation [119]. Consequently, low-context communicators listen with their ears and focus on what is being said [118]. Because of this, the use of narratives or stories in breast and cervical cancer education may be effective for these groups [129]. Stories of cancer survivors' personal experiences bring more credibility and can reinforce adherence to mammogram screening and breast self-examination recommendations [129]. Navajo Indian women test to prefer to hear personal accounts from community and family members about how they dealt with cancer, fatalism, and stigma [213]. Hmong patients, particularly older ones, tend to prefer responding in narratives to health providers' questions, which is consistent with their oral story telling traditions [214]. Western culture, including the United States, can be classified as a low-context culture. On the other hand, groups from collectivistic cultures, such as Asian/Pacific Islanders, Hispanics, Native Americans, and African Americans, are from high-context cultures [118].

Most practitioners have been taught and socialized in a Western biomedical environment in which communication styles are direct (i.e., low-context). This is evidenced by the following common behaviors [120]: